A photo representation of the cholera bacteria
Afghan authorities are rushing to chlorinate hundreds of drinking water wells across Kabul amid fears that the city could be on the verge of a cholera epidemic. International health experts say at least eight Kabul residents have died recently from an apparent waterborne disease that causes acute diarrhea and severe dehydration. Some Afghan health officials say the disease is not cholera. But whatever the case, authorities agree that poor hygiene and sanitation practices put people at risk of contracting the disease.

Prague, 16 June 2005 (RFE/RL) -- The World Health Organization says debate over the type of disease that has broken out in Kabul in recent weeks is irrelevant.

With more than 3,000 people now reporting the symptoms -- an explosive and watery form of diarrhea -- the UN's health agency says Afghans need to know that the preventive measures and treatment for the illness are the same as for cholera.

Dick Thompson is the communications officer on communicable diseases at the World Health Organization's headquarters in Geneva.

"This is likely to be a waterborne disease. So the steps that we would take for cholera -- meaning the treatment of water supplies and the providing of safe drinking water along with careful food preparation -- would be the same no matter what the cause of this outbreak is," Thompson said.

"What happens with cholera is that there is a rapid loss of fluids from the body. This can cause case fatality rates as high as 50 percent if there is not appropriate treatment."

Fred Hartman, director of a health project in Afghanistan that is funded by the U.S. Agency for International Development, says Kabul appears to be on the verge of an epidemic. He says eight or nine people have died from the diarrhea-related illness.

Abdullah Fahim, an adviser to the Afghan health minister, says the death toll is only six and that only 33 of cases of cholera have been confirmed by laboratory tests.

Fahim says all of the city's major water sources have been chlorinated along with some 700 wells -- the main source of drinking water for many Kabul residents.

Mohammad Rafi is a spokesman for UNICEF, which has been working with the Afghan government to educate the public about the disease and treat Kabul's water supplies.

"Since the beginning of this week we've started a campaign with the Afghan Health Ministry. It has two main parts. The first part is focused on raising people's awareness about health issues. It includes the necessity of drinking only clean water and washing hands. The other part of the campaign includes a program for [disinfecting] water. For example, we have helped the Health Ministry to clean all the private and public wells with chlorine," Rafi says.

Rafi tells RFE/RL the education and water treatment programs will move into provincial regions outside of the capital in the near future.

Water Borne

Thompson says the program is the right way to battle the disease.

"The most important thing is to concentrate on three things: the hygienic disposal of human feces, to provide an adequate supply of safe drinking water and finally, to conform to good food hygiene," Thompson says.

Those measures include the boiling of all drinking water and the cleaning of all food. Thompson says the skin of raw fruits and vegetables should not be eaten.

"The disease is typically spread through contaminated water -- often [contaminated] with human feces. This can cause explosive outbreaks [of diarrhea]. Generally, there is little or no human-to-human transmission. So it is important to concentrate on the source of the water -- making sure that it has been properly cleansed. And that people using water, especially as they prepare food, make sure that it is done in a hygienic way," Thompson says.

According to the World Health Organization's database on diseases, there have been at least three major outbreaks of diarrhea-related illnesses in Afghanistan during the last five years, with disturbingly high fatality rates.

It says more than 1,000 Afghans developed cholera in the summer of 2000 -- with 19 of those victims dying from the disease. That outbreak was reported in the south, west, and north of the country -- in the provinces of Kandahar, Badghis, and Jawzjan -- including parts of what is now Sar-i-Pul Province.

The next summer, the WHO reported 4,500 cases of cholera in northern, eastern, and southeastern Afghanistan. Some 114 Afghans died from cholera in 2001.

The Afghan government last reported a major outbreak of diarrheal diseases in the summer of 2002. During a period of about three weeks, nearly 7,000 Afghans developed what the WHO calls "acute watery diarrheal syndrome." Three Kabul residents died. Laboratory studies at the National Institute of Health in Islamabad later confirmed that at least three cases were cholera.

By comparison, the WHO says there were no major outbreaks of diarrhea-related illnesses during the past five years in the nearby countries of Pakistan, Iran, Tajikistan, Uzbekistan, Turkmenistan, Kazakhstan, or Kyrgyzstan. Thompson stresses that this doesn't mean there were no cases of such disease in those countries. Rather, he says, the database reflects major deadly outbreaks.

"What happens with cholera is that there is a rapid loss of fluids from the body. This can cause case fatality rates as high as 50 percent if there is not appropriate treatment. But with appropriate treatment -- and that is simply oral rehydration with salts and fluids -- the case fatality rate is very low. Often less than 1 percent. If people suspect that they or a member of their family have cholera, or if they have this explosive diarrheal syndrome, they should seek appropriate medical attention. We understand that rehydration salts are available in the region. And they should be accessed as quickly as possible," Thompson says.

The WHO also attributes outbreaks across much of Iraq in May of 2003 to the destruction of the country's sanitation infrastructure at the start of the Iraq war.

The confirmed cholera cases in Afghanistan during the past five years involve a infectious bacteria called "vibrio cholera." Thompson says it is part of an international pandemic that broke out more than 40 years ago.

"This is a bacterial infection. And this is the seventh pandemic now in progress. This began in 1961 when it first appeared in Indonesia. And it spread rapidly to other countries of eastern Asia -- reaching [what is now] Bangladesh in 1963, India in 1964 and from there, the USSR, Iran and Iraq between 1965 and 1966," Thompson says.

Thompson concludes that there is no need for authorities in neighboring countries to panic as long as their own sanitation systems are functioning and people are educated about treatment and preventive measures. The WHO also does not think that food import restrictions -- based only on the presence of a cholera-related disease in a country -- are justified.